Dental Benefit

The Dental Benefit provides coverage for certain oral surgical procedures and courses of treatment following accidental injury. Eligible expenses under the Dental Benefit are the reasonable and customary charges for these services and procedures when performed by a dentist or dental surgeon.

Lower cost alternative

When two or more courses of treatment for oral procedure or accidental injury are considered appropriate, the Plan will pay for the treatment that is least expensive.
If you choose to have the more expensive treatment, the Plan will only reimburse you up to the amount quoted for the less expensive treatment, as long as the treatment you choose is not excluded under the Plan.

Order of claiming

For oral surgery:

If you are covered under the Public Service Dental Care Plan, the Dependants Dental Care Plan, the CF Dependants Dental Care Plan or the Pensioners' Dental Services Plan, you must submit your claims for oral surgery to that plan first. Any amount not covered by your dental plan may then be submitted to the PSHCP.

Accidental injury:

You should submit your claims for accidental injury expenses to the PSHCP first.

Eligible expenses

Expenses for treatment of accidental injury

The Plan covers the services of a dental surgeon and charges for dental prosthesis when required for the treatment of a fractured jaw or accidental injuries to natural teeth if the fracture or injury was caused by an external, violent and accidental injury or blow. The Plan does not cover injuries associated with normal acts such as cleaning, chewing and eating.

Treatment must occur within 12 months following the accident or, in the case of a dependant child under 17 years of age, before attaining 18 years of age.

This time limit may be extended if, as determined by Sun Life, the treatment could not have been rendered within the time frame specified.

A physician's prescription is not required.

Expenses for oral surgical procedures

Procedure category	Specific procedure
Cysts, lesions, abscesses	Biopsy soft tissue lesion incision excision hard tissue lesion Excision of cysts Excision of benign lesion Excision of ranula Incision and drainage intra oral—soft tissue intra osseous (into bone) Periodontal abscess incision and drainage
Gingival and alveolar procedures	Alveoplasty Flap approach with curettage Flap approach with osteoplasty Flap approach with curettage and osteoplasty Gingival curettage Gingivectomy with or without curettage Gingivoplasty
Removal of teeth or roots	Removal of impacted teeth Removal of root or foreign body from maxillary antrum Root resection (apiectomy or apicoectomy) anterior teeth bicuspids molars
Fractures and dislocations	Dislocation—temporomandibular joint (or jaw) closed reduction open reduction Fractures—mandible no reduction closed reduction open reduction Fractures—maxillar or malar no reduction closed reduction open reduction open reduction (complicated)
Other procedures	Avulsion of nerve—supra or infra-orbital Frenectomy—labial or buccal (lip or cheek) Lingual (tongue) Repair of antro-oral fistula Sialolithotomy—simple Sialolithotomy—complicated Sulcus deepening, ridge reconstruction Treatment of traumatic injuries repair of soft tissue lacerations debridement, repair, suturing Torus (bone biopsy)

 

Exclusions

No benefit is payable for:

• expenses identified in the General Exclusions and Limitations of the Plan
• expenses for treatment of accidental injuries to natural teeth and oral surgical procedures other than those identified
• accidental injuries associated with normal acts such as cleaning, chewing and eating
• expenses for dental cleaning and maintenance services
• braces, retainers, headgear and other dental devices